Treemont Healthcare And Rehabilitation Center
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
AD-O, Rehab Director, Med Aide-P, CNA-Q, CNA-R, CNA-S, ADM in Training, LVN-T, RN-U, LVN-V, and LVN-W on 10/29/2025 from 1:10 PM - 3:57 PM, reflected they were in-serviced that all people not employed by the facility must sign in when they enter the facility. They stated they were in-serviced that they should not share the door code with any family members, visitors, or vendors. They stated they were in-serviced that if a resident was missing, they would call a code orange, which would indicate to all staff that a resident was missing, everyone needed to look for the missing resident, and 911 would be called if a resident was missing for 30 minutes or more. They stated that they were in-serviced that residents who are cognitively intact could sign in/out of the facility. In an interview with the Maintenance Director on 10/29/2025 at 4:01 PM, he stated he had put a cover on the keypads and changed all the codes to the outside doors. He stated that the highlighted areas on the floor plan indicated the date all the changes were made to the door codes. He stated that the staff were not supposed to share the code with any visitors or family members. In an interview with the DON on 10/29/2025 at 4:07 PM, she stated that upon hiring new staff, they would be in-serviced on the importance of not giving residents and visitors the door code, she will be conducting elopement drills with all staff. In an interview with the Regional Compliance Nurse, Administrator, DON, and ADON on 10/29/25 at 4:35 PM, they stated their manager in-service included ensuring employees who were on leave or regular day off would be in-serviced on the new door codes privacy, elopement policy, conducting elopement assessments on all residents, and abuse, neglect, and supervision. The Administrator was notified that while the IJ was removed on 10/29/2025 at 4:57 PM, the facility remained out of compliance at a scope of Isolated and a severity level of no actual harm because
the facility needed to evaluate and monitor the effectiveness of their corrective actions that were put into place. Observations of the exit doors revealed alarms were sounding, Maintenance Director observed changing the door code on the front exit door and adding a keypad cover 10/28/25 at 6:00 PM. Record
review of elopement prevention policy undated Elopement Response reflected, Policy interpretation and implementation1. It is the responsibility of all personnel to report any resident attempting to leave the premises, or suspected of being missing, to the charge nurse as soon as practical.2. Determination of missing resident either by routine nursing rounds or door alarms:A. A resident is determined missing when he/she leaves the facility without the staff's knowledge. B. A resident having a wander guard warning system that sets off an alarm by stepping outside a door and is found immediately does not constitute an elopement. C. A resident must demonstrate a free and willful intent to leave the facility without prior notification of staff or is a wandering, confused resident who leaves the facility unattended. Record review of Resident #1's progress notes dated 10/25/25 reflected, the Administrator spoke with Resident #1 and the legal representative for a coordinated discharge to the community or a transfer to the prior facility, but it was declined.Record review of in-services on elopement prevention and response, privacy of door codes, and abuse and neglect dated 10/28/25 signed by the staff in all departments and shifts. Record review of facility elopement assessments dated 10/28/25 of the current census of 74 residents, reflected no additional residents were identified as exit seeking or expressing a desire to leave the facility Record review of the facility floor plan dated 10/28/25 on all of the exit doors confirmed with the Maintenance Director that the highlighted/dated exits reflected the change of door code or covered keypad.Record review of the Administrator and DON in-service completed 10/28/25.
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Treemont Healthcare and Rehabilitation Center in Dallas, TX inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Dallas, TX, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Treemont Healthcare and Rehabilitation Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.